Provider Demographics
NPI:1154155810
Name:GUNDERSON, RENEE (BS, CSAC, LADC)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:BS, CSAC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:ROBERTS
Mailing Address - State:WI
Mailing Address - Zip Code:54023-1400
Mailing Address - Country:US
Mailing Address - Phone:715-928-0732
Mailing Address - Fax:
Practice Address - Street 1:1811 WEIR DR STE 270
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-6741
Practice Address - Country:US
Practice Address - Phone:715-928-0732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17052101YA0400X
MN307078101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)